Addiction Treatment and the Affordable Care Act (ACA)

By Celia Vimont
February 26, 2013

An Introduction
By Terence T. Gorski

The following article by By Celia Vimont summarizes the predictions made by Thomas McLellan, PhD, who reported at the 2013 annual meeting of the New York Society of Addiction Medicine that he believes that the Affordable Care Act (ACA) will revolutionize the field of substance abuse treatment.

I am not as optimistic as as Dr. McLellan about the positive impacts of the ACA on overall recovery rates for addiction clients. Here’s why;

1. When addiction services are merged into medical services the addiction tends not be diagnosed and initial referrals are made to individual doctors most who use medication management.

2. Residential Rehabilitation will not be considered an essential services.

3. Brief screening and early intervention will be attempted but relapse rates tend to be high.

4. Stigma and poly-drug abuse that mixes legal and illegal drugs will both deter early voluntary intervention.

Here is the article reporting on Dr. McLellan’s projections, which are far more optimistic than mine.
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The ACA Could Provide Substance Abuse Treatment to Millions of New Patients”

“It will have more far-reaching positive consequences for substance abuse treatment than anything in my lifetime, including the discovery of methadone,” he said at the recent annual meeting of the New York Society of Addiction Medicine.

“It will integrate substance abuse treatment into the rest of health care.”

Currently, just 2.3 million Americans receive any type of substance abuse treatment, which is less than one percent of the total population of people who are affected by the most serious of the substance use disorders—addiction, said Dr. McLellan, who is a former Deputy Director of the White House Office of National Drug Control Policy.

Most who receive treatment are severely affected, he said.
“If diabetes were treated like substance abuse, only people in the most advanced stages of illness would be covered, such as those who had already lost their vision or had severe kidney damage,” he said.

A. Thomas McLellan, PhD
Dr. McLellan reported that 23 million American adults suffer from substance abuse or dependence—about the same number of adults who have diabetes.

An additional 60 million people engage in “medically harmful” substance use, such as a woman whose two daily glasses of wine fuels growth of her breast cancer. The new law will allow millions more people to receive treatment, including those whose substance abuse is just emerging.

Under the ACA, substance abuse treatment will also become part of primary care, and will be focused more on prevention.

Substance abuse treatment will also be considered an “essential service,” meaning health plans are required to provide it. They must treat the full spectrum of the disorder, including people who are in the early stages of substance abuse. “There will be more prevention, early intervention and treatment options,” he said. “The result will be better, and less expensive, outcomes.”

By the end of 2014, under the ACA, coverage of substance use disorders is likely to be comparable to that of other chronic illnesses, such as hypertension, asthma and diabetes. Government insurers (Medicare and Medicaid) will cover physician visits (including screening, brief intervention, assessment, evaluation and medication), clinic visits, home health visits, family counseling, alcohol and drug testing, four maintenance and anti-craving medications, monitoring tests and smoking cessation.

Currently, federal benefits, such as Medicaid and Medicare, focus on inpatient services, like detox programs, but do not cover office visits for substance abuse treatments. In contrast, Medicaid covers 100 percent of diabetes-related physician visits, clinic visits and home health visits, as well as glucose tests, monitors and supplies, insulin and four other diabetes medications, foot and eye exams, and smoking cessation for diabetics.

“These are all primary care prevention and management services, which are the most effective and cheapest way of managing illness,” he said.

The impact of these new rules will be quite substantial, since an estimated 65 percent of insured Americans are covered by Medicaid or Medicare, and the rest are covered by insurance companies that base their benefits structure on federal benefits, said Dr. McLellan.

As addiction becomes treated as a chronic illness, pharmaceutical companies will be much more interested in developing new medications, he added.

“Immense markets are being created,” he said. “Until now, there have been about 13,000 treatment providers for substance use disorders, and less than half of those are doctors. Now, 550,000 primary care doctors, in addition to nurses who can prescribe medications, will be caring for these patients.”

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4 Responses to Addiction Treatment and the Affordable Care Act (ACA)

I agree with Mr. Gorski. From my long experience in the field (29 years) I have seen an increase in physicians education about substance abuse in their education but it still has a ways to go in my opinion. Many doctors shy away from asking important questions about substance use and abuse. Medications can be very helpful for some individuals compared to years ago in the days of antabuse and naltrexone but certainly not everyone.

Terry am I missing something here or does this make us a completely harm reduction society? I know very few doctors that would even be able to discuss high-risk situation, addiction understanding and so on. To have 550,000 MD, PA & NP’s giving medication without education is scary! Our society is already over medicated!

WARNING: POLITICAL INCORRECT MATERIAL — ONLY RATIONAL PEOPLE SHOULD READ ON!
In discussing Addiction Treatment and theAffordable Care Act it is 9important to understand that the ACA itself is poorly organized and does precisely describe addiction. The concepts of abuse and addiction are merged into one, as they are into DSM 5. The issue of addiction severity being linked to level and intensity o treatment is not clearly defined. Nor are the licensed professional grouse or the type of degreed professionals that will be allowed by government to treat addicts.
The entire goal of the ACA is to integrate addiction treatment (alcohol and other drug abuse) into the general health care system and be sure to incentive the lowest cost of care. Many of the details are up to the states as they implement, and the individual insurance companies as they develop strict coverage criteria, and managed care providers who will decide upon the admission, discharge and continuing care criteria.
Om my opinion, you are right. Addicts are over-medicated often with meds that don’t work. The driving force of the high level policy are the Psychiatrists who were most influential in DSM 5. They are heavily influence by big pharma, who wants all Narcotics Addicts treated with Suboxone. The cost is only lower if most counseling and therapy is withheld.
In the 1980’s, managed care companies “carved out” mental health and addiction services so separate stands could be developed because addicts cannot receive appropriate care with general medical-surgical guidelines. The model that I have herds and red for the upcoming policy is that “we need to treatment like diabetics or other people with medical illness.”
In spite of what many people believe, the ACA is about cutting costs by regulating instance and giving the government more power to regulate. It has nothing to do with improving treatment or producing better outcomes. For example, the ACA has nothing to say about how addiction treatment should be done in jails and whether or not the restriction on funding which prevents convicted felony criminals to get treatment will continue.
The ACA, in my opinion, is a mess. The private treatment industry waited back passively and now it is too late.
The real problem is that the high level academics consulting on the act know little or nothing on a practical level about addiction treatment. Yet they set the policies. Big hospitals will do medical detox, residential rehabilitation is not part of the basic coverage guarantees, and most work will be in short term outpatient treatment. The role of psychiatrists and MD’s in treatment will become stronger. In spite of more advanced degrees, the credibility and policy input of other professional groups will be diminished.
I don’t believe that much will change because most people in the field are just to over-worked and underpaid to become politically active. It is time for a grass roots revolution against the irrational and non-science that is being used to define addiction and it’s treatment under this act. The confusing language and neglect of addiction in the education of professional in advanced degree programs works against this.
The massive policy conflict between the WAR ON DRUGS POLICY and the PUBLIC HEALTH ADDICTION POLICY has been ignored.
I doubt the this really clears up anything. Poorly written and politically motivated legislation is usually the irrational result of committees. A donkey is the result of a committee assigned to develop a race horse. A come is the result of the over-sight committee assigned to make the donkey look more like a race horse.
I suggest forcefully presenting the results of your clinical experience in writing here and elsewhere. you have a voice. Use it. (Unproofed response.)

There is a strong move toward harm reduction especially in the areas of narcotics treatment via Suboxone managed out of physicians offices for long-term maintenance. I do not a agree with this approach. In my opinion, harm reduction methods should be integrated into the continuum of care are every opportunity to should be offered to motivate patients into higher levels of care that will result in life-enhancement not just harm reduction.